Francis G. Wolfort, M.D., Erik Sorrel Dejerine, M.D., Douglas J. Ramos, M.D., and Richard G. Parry, M.D.
INTRODUCTION IN HUNGARIAN / BEVEZETŐ MAGYARUL
Prominent thyroid cartilage (pomus Adamus) is frequently a constant embarrassment to the male transsexual as well as to the asthenic male.1 The request for surgical reduction and contouring of the prominent "Adam's apple" continues to increase in our societies today.
We present a review of our technique of chondrolaryngoplasty with refinements since its first presentation,2 and anatomic details and a follow-up of 31 patients ranging from 4 months to 17 years. The results are effective and satisfying, with few complications. Those which do occur tend to be transient, with the most frequent being a temporary mild voice weakness. We believe this operation has a place among the techniques of plastic surgeons.
Prominent thyroid cartilage (pomus Adamus) is frequently a constant embarrassment to the male transsexual as well as to the asthenic male.1 The request for surgical reduction and contouring of the prominent "Adam's apple" continues to increase in our societies today.
We present a review of our technique of chondrolaryngoplasty with refinements since its first presentation,2 and anatomic details and a follow-up of 31 patients ranging from 4 months to 17 years. The results are effective and satisfying, with few complications. Those which do occur tend to be transient, with the most frequent being a temporary mild voice weakness.
Anatomy
Until puberty, the larynx of the male differs little in size from that of the female.3 At and after puberty, the male larynx enlarges significantly, with an increase in all the cartilaginous components, especially the thyroid cartilage. This projects and becomes prominent in the anterior midline of the neck, while the anteroposterior diameter of the larynx is nearly doubled.3
The laryngeal prominence ("Adam's apple") is formed by the fusion of the anterior borders of the two laminae of the thyroid cartilage,4 diverging at an angle of approximately 90 degrees in the male and 120 degrees in the female.3 Since this angle is wider in the female, the prominence is usually much less in the female.
The laryngeal prominence is most distinct superiorly (Fig. 1), and immediately above it the laminae are separated by a V-shaped notch, the superior thyroid notch (Fig. 2). Examination of the anatomic relationship of the thyroid cartilage to the laryngeal muscles, epiglottis, and vocal cords reveals that the prominent portion of the male larynx may be removed without damage to these structures (Fig. 3).
On the lateral external surface of the thyroid cartilage, the attachments of the stylopharyngeus, the inferior pharyngeal constrictor, the sternothyroid, and the thyrohyoid muscles are all located posterior to an oblique line that runs caudal and anterior from the superior thyroid
tubercle (inferior to the superior cornu) to the inferior thyroid tubercle (lower border of the lamina)5 (Fig. 1). Internally, the epiglottis attaches to the inner surface of the midline of the thyroid cartilage, by the thyroepiglottic ligament, well below the superior thyroid notch. Inferior to this ligament and protected by it lie the attachments to the false vocal cord superiorly and to the true vocal cord inferiorly. Both structures lie within the midline (Fig. 2).
The thyrohyoid membrane, a broad fibroelastic sheet, is attached from the superior border of the laminae and anterior border of the superior horns to the upper margin of the posterior surface of the body of the hyoid bone. The middle part of the membrane is thicker and forms the median thyrohyoid ligament.
The superior laryngeal nerves divide into the internal and external laryngeal nerves. The internal laryngeal nerve penetrates the thyrohyoid membrane in its posterior half (Fig. 1) cephalad to the superior laryngeal artery and vein and the superior margin of the thyroid cartilage.3-5 Branches of this nerve supply sensation to the larynx above the glottis.
The external branch of the superior laryngeal nerve descends along the posterior border of the thyroid cartilage, protected by the thyrohyoid muscle, to supply the cricothyroid muscle. The recurrent laryngeal nerve enters the larynx beneath the posteroinferior margin of the cricothyroid muscle, at the caudal border of the inferior pharyngeal constrictor.
Operative Technique
Under general anesthesia, with endotracheal intubation and after local subcutaneous infiltration (Xylocaine 1% with epinephrine), the skin, subcutaneous tissue, and investing layer of the deep cervical fascia are incised and opened transversely. A conveniently located skin crease is used. The middle cervical fascia is then divided vertically in the midline, and the sternothyroid and thyrohyoid muscles are retracted laterally to expose the thyroid cartilage (Fig. 4).
The perichondrium on the external rim of the superior border of the thyroid cartilage is incised commencing approximately halfway between the superior thyroid tubercle and the superior thyroid notch across the midline to the same point on the opposite side along the rim. Care is taken to stay on the rim to prevent entering the thyrohyoid membrane. The perichondrium on the outside of the laminae is elevated using a Cottle elevator to a level adequate for the cartilaginous resection (Fig. 5). On the inside of the laminae,
the perichondrium and the thyrohyoid membrane are elevated to the level of the thyroepiglottic ligament.
Dissection beyond this point may damage the vocal cords and stabilization of the epiglottis. The prominent outwardly rolled superior rim, the superior notch, the upper part of the laryngeal prominence, and the upper portions of the laminae are then obliquely excised (Fig. 6). If needed, the edges are smoothed with a burr to refine the contouring. The two perichondrial flaps are then sutured together (resorbable 5-0 suture). If necessary, a small rubber catheter is used for drainage. A careful layered closure completes the operation.
Results
Since 1972, 31 patients have been operated, 11 thin males and 20 male transsexuals, with a mean follow-up of 10 years. None has had hematoma, infection, laryngocutaneous fistula, permanent loss of voice, laryngeal edema necessitating
respiratory assistance, or anesthesia of the larynx or neuralgia of the superior laryngeal nerve.
Twenty-one patients had mild hoarseness and/or mild voice weakness. This was transient, generally resolving in less than 20 days, with one persisting for 6 months. Fourteen patients complained of mild pain in swallowing; this also was transient, resolving in 2 to 3 days. None has had problems with deglutition or aspiration.
The results have been satisfactory (Figs. 7 to 10). Our long follow-up shows permanent results, with no regrowth of the resected cartilage noted.
Discussion
Chondrolaryngoplasty is performed as outpatient surgery under general anesthesia. Verification of the integrity of the vocal cords and their mobility is performed with a laryngoscope during the extubation. We have noted a slight edema of the cords at the end of the procedure. No patients have required reintubation or steroids, though the latter may help some of the transient problems.
Although no textbook of anatomy mentions any asymmetry in thyroid cartilage, we have noticed that often the right lamina is larger than the left, requiring a wider resection. (Fig. 11). Since the thyroid cartilage is a hyaline cartilage, it becomes more or less ossified as age advances.3 Hence its resection may be difficult with blade, necessitating the use of fine rongeurs.
Neither the patients nor their families and friends have noticed a change in voice tonality, since there is no significant modification of the
functional parts of the larynx. In particular, the angle of the laminae is not changed.
None of our patients experienced any aspiration. The stabilization of the epiglottis is maintained by a cautious dissection, avoiding any damage to the thyroepiglottic ligament, and by the attachment of the tongue and the hyoepiglottic ligament. None of the patients showed
Fig. 9. (Left) Preoperative lateral view of a thin man with a prominent Adam's apple. Note laryngeal prominence.
(Right) Preoperative front view of a thin man with a prominent Adam's apple. Note laryngeal prominence.
Fig. 10. (Left) Postoperative lateral view of the same thin man with a prominent Adam's apple. Note reduction in laryngeal prominence.
(Right) Postoperative front view of the same thin man with a prominent Adam's apple. Note reduction in laryngeal prominence.
any clinically tested anesthesia of the larynx or neuralgia of the superior laryngeal nerve. The nerve is easily protected during the operation.
Alerted by Edgerton to the risks of this kind of procedure,1 we have been very cautious in our dissections and have instructed the patients to use an aerosol for the first 4 or 5 postoperative days. Hence, although it has been the most frequent complication, the mild voice weakness observed postoperatively was very transient, most lasting less than 20 days. One case of more persistent voice weakness lasted 6 months. Perhaps this way due to prolonged edema and may have benefited from steroid administration.
No evidence of any regrowth or other modification of the shape of the thyroid cartilage was found in follow-up. More extensive postoperative documentation of regrowth (using xerography for instance) was not performed.
Hormones were not noted to influence the regrowth of the cartilage, although the male transsexuals were medicated with female hormones on a regular basis.
An augmenting chondrolaryngoplasty in the female transsexuals has not been performed but probably could be carried out with a similar anatomic approach.
Conclusion
A good knowledge of the anatomy and a cautious technique are prerequisites for good results in the surgical reduction and contouring of the Adam's apple in the male transsexual as well as in the thin male. This operation has a place among the techniques of the plastic surgeon, since the results are effective, satisfying, and long-lasting.
Francis G. Wolfort, M.D.
Department of Plastic Surgery
New England Deaconess Hospital
Harward medical School
Suite 8F
110 Francis Street
Boston, Mass. 02215
Acknowledgements
The authors wish to thank the Department of Photo services of the Beth Israel Hospital, Boston, for the illustrations and Dr. Stephen Sohn for the photographs (Figs. 9 and 10).
References
Chondrolaryngoplasty for Appearance
Francis G. Wolfort, M.D., Erik Sorrel Dejerine, M.D., Douglas J. Ramos, M.D., and Richard G. Parry, M.D.
Discussion by Milton T. Edgerton, M.D.
This is a concise, well-written description of a useful operation that is know to only a minority of plastic surgeons. Patients, especially male-to-female transsexuals, find that this reduction of the large Adam's apple greatly relieves their feelings of gender dysphoria. The series is of adequate size and is meaningful as a long-term follow-up.
It is of interest that two-thirds of the patients experienced postoperative hoarseness or voice weakness. None is reported to have persistence of this problem. This reviewer also has encountered this complication, and on two occasions, I followed patients with voice "weakness" (i.e., hoarseness on talking for over 30 to 40 minutes) that continued for over a year postoperatively. In both patients, the cartilage resection was about 20 percent greater than the amount described as removed by the authors.
I also remain uneasy about sending these patients home on the evening of surgery. Mild postoperative laryngeal edema and respiratory obstruction are present in most, even with steroid administration. A relatively small hematoma or unusual edema could easily require a reintubation or tracheostomy on short notice. For this reason, I usually admit these patients for 24 hours.
The anatomic details presented by the authors are excellent and will be most useful to plastic surgeons who have not been exposed to this type of surgery.
Milton T. Edgerton, M.D.
Department of Plastic Surgery
University of Virginia Hospital
Charlottesville, Va. 22908
PLASTIC AND RECONSTRUCTIVE SURGERY, September 1990 Vol. 86, No.3 (464-470) - Page: 464
Boston, Mass.INTRODUCTION IN HUNGARIAN / BEVEZETŐ MAGYARUL
Prominent thyroid cartilage (pomus Adamus) is frequently a constant embarrassment to the male transsexual as well as to the asthenic male.1 The request for surgical reduction and contouring of the prominent "Adam's apple" continues to increase in our societies today.
We present a review of our technique of chondrolaryngoplasty with refinements since its first presentation,2 and anatomic details and a follow-up of 31 patients ranging from 4 months to 17 years. The results are effective and satisfying, with few complications. Those which do occur tend to be transient, with the most frequent being a temporary mild voice weakness. We believe this operation has a place among the techniques of plastic surgeons.
Prominent thyroid cartilage (pomus Adamus) is frequently a constant embarrassment to the male transsexual as well as to the asthenic male.1 The request for surgical reduction and contouring of the prominent "Adam's apple" continues to increase in our societies today.
We present a review of our technique of chondrolaryngoplasty with refinements since its first presentation,2 and anatomic details and a follow-up of 31 patients ranging from 4 months to 17 years. The results are effective and satisfying, with few complications. Those which do occur tend to be transient, with the most frequent being a temporary mild voice weakness.
Anatomy
Until puberty, the larynx of the male differs little in size from that of the female.3 At and after puberty, the male larynx enlarges significantly, with an increase in all the cartilaginous components, especially the thyroid cartilage. This projects and becomes prominent in the anterior midline of the neck, while the anteroposterior diameter of the larynx is nearly doubled.3
The laryngeal prominence ("Adam's apple") is formed by the fusion of the anterior borders of the two laminae of the thyroid cartilage,4 diverging at an angle of approximately 90 degrees in the male and 120 degrees in the female.3 Since this angle is wider in the female, the prominence is usually much less in the female.
The laryngeal prominence is most distinct superiorly (Fig. 1), and immediately above it the laminae are separated by a V-shaped notch, the superior thyroid notch (Fig. 2). Examination of the anatomic relationship of the thyroid cartilage to the laryngeal muscles, epiglottis, and vocal cords reveals that the prominent portion of the male larynx may be removed without damage to these structures (Fig. 3).
On the lateral external surface of the thyroid cartilage, the attachments of the stylopharyngeus, the inferior pharyngeal constrictor, the sternothyroid, and the thyrohyoid muscles are all located posterior to an oblique line that runs caudal and anterior from the superior thyroid
 Fig.1. Lateral view of the larynx. The laryngeal prominence is most distinct superiorly. |
 Fig. 2. Posterior view of the thyroid cartilage. |
 Fig. 3. Schematic representation of the thyroid cartilage resection. |
The thyrohyoid membrane, a broad fibroelastic sheet, is attached from the superior border of the laminae and anterior border of the superior horns to the upper margin of the posterior surface of the body of the hyoid bone. The middle part of the membrane is thicker and forms the median thyrohyoid ligament.
The superior laryngeal nerves divide into the internal and external laryngeal nerves. The internal laryngeal nerve penetrates the thyrohyoid membrane in its posterior half (Fig. 1) cephalad to the superior laryngeal artery and vein and the superior margin of the thyroid cartilage.3-5 Branches of this nerve supply sensation to the larynx above the glottis.
The external branch of the superior laryngeal nerve descends along the posterior border of the thyroid cartilage, protected by the thyrohyoid muscle, to supply the cricothyroid muscle. The recurrent laryngeal nerve enters the larynx beneath the posteroinferior margin of the cricothyroid muscle, at the caudal border of the inferior pharyngeal constrictor.
Operative Technique
Under general anesthesia, with endotracheal intubation and after local subcutaneous infiltration (Xylocaine 1% with epinephrine), the skin, subcutaneous tissue, and investing layer of the deep cervical fascia are incised and opened transversely. A conveniently located skin crease is used. The middle cervical fascia is then divided vertically in the midline, and the sternothyroid and thyrohyoid muscles are retracted laterally to expose the thyroid cartilage (Fig. 4).
The perichondrium on the external rim of the superior border of the thyroid cartilage is incised commencing approximately halfway between the superior thyroid tubercle and the superior thyroid notch across the midline to the same point on the opposite side along the rim. Care is taken to stay on the rim to prevent entering the thyrohyoid membrane. The perichondrium on the outside of the laminae is elevated using a Cottle elevator to a level adequate for the cartilaginous resection (Fig. 5). On the inside of the laminae,
 Fig.4. Exposure of the thyroid cartylage. |
 Fig.5. The perichondrial flaps are raised. |
Dissection beyond this point may damage the vocal cords and stabilization of the epiglottis. The prominent outwardly rolled superior rim, the superior notch, the upper part of the laryngeal prominence, and the upper portions of the laminae are then obliquely excised (Fig. 6). If needed, the edges are smoothed with a burr to refine the contouring. The two perichondrial flaps are then sutured together (resorbable 5-0 suture). If necessary, a small rubber catheter is used for drainage. A careful layered closure completes the operation.
Results
Since 1972, 31 patients have been operated, 11 thin males and 20 male transsexuals, with a mean follow-up of 10 years. None has had hematoma, infection, laryngocutaneous fistula, permanent loss of voice, laryngeal edema necessitating
 Fig.6. The limit of the cartilaginous resection is outlined on the cartilage. |
Twenty-one patients had mild hoarseness and/or mild voice weakness. This was transient, generally resolving in less than 20 days, with one persisting for 6 months. Fourteen patients complained of mild pain in swallowing; this also was transient, resolving in 2 to 3 days. None has had problems with deglutition or aspiration.
The results have been satisfactory (Figs. 7 to 10). Our long follow-up shows permanent results, with no regrowth of the resected cartilage noted.
Discussion
Chondrolaryngoplasty is performed as outpatient surgery under general anesthesia. Verification of the integrity of the vocal cords and their mobility is performed with a laryngoscope during the extubation. We have noted a slight edema of the cords at the end of the procedure. No patients have required reintubation or steroids, though the latter may help some of the transient problems.
Although no textbook of anatomy mentions any asymmetry in thyroid cartilage, we have noticed that often the right lamina is larger than the left, requiring a wider resection. (Fig. 11). Since the thyroid cartilage is a hyaline cartilage, it becomes more or less ossified as age advances.3 Hence its resection may be difficult with blade, necessitating the use of fine rongeurs.
Neither the patients nor their families and friends have noticed a change in voice tonality, since there is no significant modification of the
 Fig. 7. (Left) Preoperative lateral view of a male transsexual. Note laryngeal prominence. (Right) Preoperative front view of same male transsexual. Note laryngeal prominence. |
 Fig. 8. (Left) Postoperative lateral view of the same male transsexual. Note reduction in laryngeal prominence. (Right) Postoperative front view of the same male transsexual. Note reduction in laryngeal prominence. |
None of our patients experienced any aspiration. The stabilization of the epiglottis is maintained by a cautious dissection, avoiding any damage to the thyroepiglottic ligament, and by the attachment of the tongue and the hyoepiglottic ligament. None of the patients showed
Fig. 9. (Left) Preoperative lateral view of a thin man with a prominent Adam's apple. Note laryngeal prominence.
(Right) Preoperative front view of a thin man with a prominent Adam's apple. Note laryngeal prominence.
Fig. 10. (Left) Postoperative lateral view of the same thin man with a prominent Adam's apple. Note reduction in laryngeal prominence.
(Right) Postoperative front view of the same thin man with a prominent Adam's apple. Note reduction in laryngeal prominence.
 Fig.11. Operative resection specimens of the thyroid cartilage showing the asymmetry of the two laminae. |
Alerted by Edgerton to the risks of this kind of procedure,1 we have been very cautious in our dissections and have instructed the patients to use an aerosol for the first 4 or 5 postoperative days. Hence, although it has been the most frequent complication, the mild voice weakness observed postoperatively was very transient, most lasting less than 20 days. One case of more persistent voice weakness lasted 6 months. Perhaps this way due to prolonged edema and may have benefited from steroid administration.
No evidence of any regrowth or other modification of the shape of the thyroid cartilage was found in follow-up. More extensive postoperative documentation of regrowth (using xerography for instance) was not performed.
Hormones were not noted to influence the regrowth of the cartilage, although the male transsexuals were medicated with female hormones on a regular basis.
An augmenting chondrolaryngoplasty in the female transsexuals has not been performed but probably could be carried out with a similar anatomic approach.
Conclusion
A good knowledge of the anatomy and a cautious technique are prerequisites for good results in the surgical reduction and contouring of the Adam's apple in the male transsexual as well as in the thin male. This operation has a place among the techniques of the plastic surgeon, since the results are effective, satisfying, and long-lasting.
Francis G. Wolfort, M.D.
Department of Plastic Surgery
New England Deaconess Hospital
Harward medical School
Suite 8F
110 Francis Street
Boston, Mass. 02215
Acknowledgements
The authors wish to thank the Department of Photo services of the Beth Israel Hospital, Boston, for the illustrations and Dr. Stephen Sohn for the photographs (Figs. 9 and 10).
References
- Edgerton, M. T. The surgical treatment of male transsexuals. Clin. Plast. Surg. 1: 285, 1974.
- Wolfort, F. G., and Parry, R. G. Laryngeal chondroplasty for appearance. Plast. Reconstr. Surg. 56: 371, 1975.
- Williams, P., and Warwick, R. (Eds.) Gray's Anatomy, 36th british Ed. Phiadelphia: Saunders, 1980. Pp. 1229-1236.
- Goss, C. M. Anatomy of the Human Body, 27th Ed. Philadelphia: Lea & Febiger, 1959.
- Hast, M. Anatomy of the Larynx. In G. English (Ed.) Otolaryngology, Vol. 3. Philadelphia: Harper & Row, 1987
Chondrolaryngoplasty for Appearance
Francis G. Wolfort, M.D., Erik Sorrel Dejerine, M.D., Douglas J. Ramos, M.D., and Richard G. Parry, M.D.
Discussion by Milton T. Edgerton, M.D.
This is a concise, well-written description of a useful operation that is know to only a minority of plastic surgeons. Patients, especially male-to-female transsexuals, find that this reduction of the large Adam's apple greatly relieves their feelings of gender dysphoria. The series is of adequate size and is meaningful as a long-term follow-up.
It is of interest that two-thirds of the patients experienced postoperative hoarseness or voice weakness. None is reported to have persistence of this problem. This reviewer also has encountered this complication, and on two occasions, I followed patients with voice "weakness" (i.e., hoarseness on talking for over 30 to 40 minutes) that continued for over a year postoperatively. In both patients, the cartilage resection was about 20 percent greater than the amount described as removed by the authors.
I also remain uneasy about sending these patients home on the evening of surgery. Mild postoperative laryngeal edema and respiratory obstruction are present in most, even with steroid administration. A relatively small hematoma or unusual edema could easily require a reintubation or tracheostomy on short notice. For this reason, I usually admit these patients for 24 hours.
The anatomic details presented by the authors are excellent and will be most useful to plastic surgeons who have not been exposed to this type of surgery.
Milton T. Edgerton, M.D.
Department of Plastic Surgery
University of Virginia Hospital
Charlottesville, Va. 22908
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